Mid-upper arm circumference predicts death in adult patients admitted to a TB ward in the Philippines: A prospective cohort study.

BACKGROUND: The Philippines is ranked 3rd globally for tuberculosis incidence (554/100,000 population). The tuberculosis ward at San Lazaro Hospital, Manila receives 1,800-2,000 admissions of acutely unwell patients per year with high mortality. Objectives of this prospective cohort study were to quantify the association of under-nutrition (primary) and diabetes (secondary) with inpatient mortality occurring between 3-28 days of hospital admission in patients with suspected or previously diagnosed TB. METHODS AND RESULTS: We enrolled 360 adults (≥18 years); 348 were eligible for the primary analysis (alive on day 3). Clinical, laboratory, anthropometric and enhanced tuberculosis diagnostic data were collected at admission with telephone tracing for mortality up to 6 months post-discharge. In the primary analysis population (mean age 45 years, SD = 15.0 years, 70% male), 58 (16.7%) deaths occurred between day 3-28 of admission; 70 (20.1%) between day 3 and discharge and documented total post-day 3 mortality including follow-up was 96 (27.6%). In those in whom it could be assessed, body mass index (BMI) ranged from 11.2-30.6 kg/m2 and 141/303 (46.5%) had moderate/severe undernutrition (BMI<17 kg/m2). A sex-specific cut-off for mid-upper arm circumference predictive of BMI<17 kg/m2 was associated with inpatient Day 3-28 mortality in males (AOR = 5.04, 95% CI: 1.50-16.86; p = 0.009; p = 0.032 for interaction by sex). The inability to stand for weight/height for BMI assessment was also associated with mortality (AOR = 5.59; 95% CI 2.25-13.89; p<0.001) as was severe compared to normal/mild anaemia (AOR = 9.67; 95% CI 2.48-37.76; p<0.001). No TB specific variables were associated with Day 3-28 mortality, nor was diabetes (HbA1c ≥6.5% or diabetes treatment). Similar effects were observed when the same multivariable model was applied to confirmed TB patients only and to the outcome of all post-day 3 in-patient mortality. CONCLUSION: This research supports the use of mid-upper arm circumference for triaging acutely unwell patients and the design and testing of nutrition-based interventions to improve patient outcomes.

Nationwide HIV-, MDR-TB survey in Japan and collaborative study in the Philippines.

BACKGROUND: Although the prevalence of pulmonary tuberculosis (TB) and HIV infection in Japan is low, careful monitoring of these two diseases is necessary. We conducted a nationwide survey on multidrug resistant (MDR)-TB (2011-2013) and HIV-TB (2007-2014) to understand the mode of prevention and the effect of therapy. A study on MDR-TB and HIV in San Lazaro Hospital (SLH) in the Philippines was also conducted. These studies introduced an international collaborative study against the global epidemics of HIV-TB/MDR-TB. METHODS: The nationwide survey of MDR-TB was done in hospitals that treat TB patients in Japan from 2011 to 2013. The HIV-TB survey has been done every year since 2007. Classic information such as chest X-ray (CXR) as well as computed tomography (CT) results for each patient were analyzed. Likewise, the presence of a cavity, involved segments, and patterns of parenchymal lesion were assessed. Finally, tentative diagnosis and disease activity, bronchogenic spread of the lesion with CT, and bronchiectasis were recorded. At SLH, sputa of suspected cases were subjected to GeneXpert testing and HIV testing was performed on all TB patients. RESULTS: In the nationwide MDR survey in Japan, 171 patients were diagnosed as pulmonary MDR-TB (0.2% of total Mycobacterium tuberculosis (MTB) in Japan). Among them, 48 (28%) were foreigners and most were living in big cities. In Tokyo metropolitan areas, 27 out of 53 MDR-TB patients were foreigners: 13 were from China, 4 from the Philippines, and 3 from Myanmar. Thirty nine among 53 MDR-TB patients were cured or treatment was completed with favorable prognosis. Five deaths (9.4%) and six departures from Japan (11.3%) were noted. In the HIV-TB survey in National Hospitals, the HIV-positive rates on MTB were constantly low (0.23-0.46%) from 2007 to 2014. Among the reported 114 HIV-TB patients (0.37% of total MTB in National Hospitals), 17 were foreigners and 3 (2.6%) were MDR-TB cases (2 Chinese, 1 Japanese). Half of the HIV-TB patients have low CD4 cell numbers (<100/µL). Two out of the 3 MDR-TB patients were cured. Imme reconsitution inflammatory syndrome (IRIS) was found in 48% of all HIV-TB cases. At SLH in the Philippines, total numbers of GeneXpert examined cases were 1052 cases in 2015, and 122 Rifampicin resistant (RR)-TB cases (11.6%) were found and among the enrolled 96 cases 14 (15%) were found to be HIV positive. CONCLUSION: Very low numbers of TB or HIV patients have been observed in Japan. An increasing number of foreign-born MDR-TB patients in the country was found. To combat against these global epidemics, an international collaboration against HIV-TB/MDR-TB is needed.